Autonomy Blog

What Do You Mean by Autonomy?

The following article appears in the fall 2011 issue of Quickening, now arriving in ACNM member mailboxes. We were curious what our members had to say about the article and the idea of autonomy, so we decided to bring the discussion online. We encourage your questions and comments!

by ACNM Executive Director Lorrie Kline Kaplan, CAE

I have been struck lately by the power and nuances of the word “autonomy” in the current health policy environment, and how the word means surprisingly different things to different people.

One of ACNM’s strategic goals is to achieve autonomy for midwifery practice. In most cases, the word autonomy is used as a synonym for the word “independent.” ACNM’s 2004 position statement “Independent Midwifery Practice,” describes midwifery practice as the “independent management of women’s health care…” while cautioning that this should not “be interpreted to mean alone, as there are clinical situations when any prudent practitioner would seek the assistance of another qualified practitioner.”

It sounds straightforward, but when we dig a little deeper, differences emerge. Some midwives define autonomy as the establishment of midwifery as a profession distinct and separate from nursing. From this perspective, midwives will be autonomous only when our profession has disentangled from nursing at the academic, regulatory, and other levels. Others believe that alignment with nursing is consistent with the goal of autonomy. Their view is that our long-standing and trusting educational and regulatory relationships with nursing—especially advanced practice nursing—will help us achieve autonomy for midwifery. They favor joining forces with an advanced practice registered nurse (APRN) community which has grown much stronger in recent years, shares our goals, and is willing to put resources behind achieving them.

For some physicians, autonomy for midwives (and/or APRNs) is unsettling at best, and often just plain unacceptable. Too frequently, they interpret our quest for autonomy as a desire to work without any contact with physicians. Our standards of practice require that we collaborate and refer based on the needs of our clients, but this message often gets lost. We must repeatedly and patiently bring it back to the forefront.

In order to achieve the strategic goal of autonomous practice, we must ask, “What is the biggest obstacle in the way?” We have resoundingly heard from our members that, on a day-to-day basis, the biggest obstacles come in the form of requirements for physician supervision or for signed collaborative practice agreements. These requirements proliferate in state and federal laws and spill over into Joint Commission requirements, hospital policies, and insurance rules. They block access to midwifery care to the extent that it is difficult for midwives to practice in some states—despite legal recognition. (Want to know which ones? Check out the state-by-state statistics on midwife-attended births on the ACNM Web site. Studies have demonstrated that when these requirements are removed, access to care from CNMs/CMs and APRNs increases without compromising quality or safety.

The midwifery community has made remarkable strides in achieving autonomous practice and legal recognition, but we still have a long road to travel. We continue to make progress month-to-month, thanks to an incredible team effort at all levels of our community. We believe that our success in achieving this goal will be enhanced by working creatively and innovatively with all stakeholders—including nursing and medicine. The first step in gaining their support is that they understand our definition of autonomy. The second step is showing them what we’re made of. Show them our professionalism, our expertise, our competence, our skill in listening to women, and our deep belief in respectful collaboration as the best way to take care of the women we serve.

We’d like to hear more from you on this topic. How do you define autonomy? Do you practice autonomously? If not, what is standing in your way? Who are your biggest supporters? What advice can you share from your experiences? Let’s keep talking about this! Post your comments below.